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Tuesday, 9 October 2012

My Dietary Recommendations for Liver Health

These are the notes I hand out at my inpatient liver presentations.
They do not promote carbohydrate restriction because they are aimed at people with alcohol and drug issues who more often than not need to eat more of (almost) everything. Nor do they include supplements, as supplementation is decided on a case-by-case issue for inpatients.
Apart from that, it includes everything I had learned about a year ago...


The type of diet, and the specific foods you eat, can play a large
role in recovery from liver damage. A few substances found in common
foods can promote liver fibrosis; many specific foods have been shown,
or are suspected, to prevent it.
In general terms
1) Protein is very protective of the liver,
2) Complex carbohydrate (starch) is protective but simple (sweet)
sugars can be harmful, and
3) Saturated fat is protective, while polyunsaturated fat can be harmful.

There are 3 specific substances to minimize or avoid:

Fructose (found in sugar, corn syrup, fruit juice concentrate, agave
juice, honey, as well as sweet fruit).
Fructose is directly converted to fat in the liver and reduces the
insulin response to glucose; high consumption of fructose can cause
fatty liver, type 2 diabetes, gout and irritable bowel syndrome.
Whole fruit and dark honey, in limited amounts, are safe sources of
fructose for most people.
(In the Hepatitis C Virus (HCV) life cycle, fructose induces DGAT1 and
promotes VLDL expression, increasing the release of virus to the

Polyunsaturated fats; PUFAs (from vegetable oils and non-dairy
spreads). These fats are essential only in such amounts as one might
easily obtain from a diet containing meat, dairy, eggs, and fish, with
occasional nuts and seeds. Vegetable oils contain large quantities of
omega-6 lineolic acid, which promotes inflammation and suppresses
omega-3 fats.
The popularity of omega-3 fish oil in modern times is due to the
excessive amount of omega-6 in food oils and processed foods.
When large amounts of polyunsaturated fats are added to alcohol or
drugs, liver damage and fibrosis are increased.
Persons with Hepatitis C show increased fibrosis and worse responses
to treatment with higher PUFA content of the diet.
Vegetable oils decrease LDL and HDL cholesterol, while saturated
animal fats increase both. In persons with Hep C, higher LDL and total
cholesterol is associated with a lower degree of fibrosis and a better
response to treatment.
(In the HCV life cycle, low LDL causes an increase in LDL-receptors,
which are used by the virus to infect new cells).
The fat from pork and poultry is relatively high in omega-6 PUFA, and
is not protective, whereas fat from beef, lamb, goat, venison, dairy,
cocoa, and coconut is protective.

Minimize, and if possible Avoid:
Gluten grains.
Wheat (flour, bread, pastry etc.), Rye, Barley, Spelt, Kamut, Oats.
These grains contain glutenin and gliadin (proteins), together with
agglutinating lectins, phytates, and fructose-containing fibre (FOS),
which can damage the gut when consumed in the excessive amounts found
in the modern diet (it’s not just the gluten that’s harmful in these
foods). Whole grains contain more agglutinin lectins, phytates, and
FOS than white flour, which is however lacking in most vitamins and
contains added iron.
Gluten grains cause “leaky gut” (increased intestinal permeability)
which allows bacteria and toxic undigested proteins to enter the
bloodstream from the gut.
Parts of these bacteria called LPS can trigger inflammation in the
Persons with Hepatitis C have an increased rate of Coeliac disease, a
gluten sensitivity disease. Coeliac and non-celiac gluten sensitivity
can cause liver cirrhosis, gall bladder disease, and diabetes (types 1
and 2), as well as most of the autoimmune diseases common in people
with Hepatitis C.
Humans have been eating grains for a relatively short period of our
history and have not had time to adapt properly to a food that poses
so many digestive challenges.
Grains supply no nutrients not found in other foods; meat, eggs,
dairy, nuts and seeds are better sources of protein, vitamins and
essential fats, while root vegetables and tubers are better sources of
starches, and green vegetables are richer in protective
phytochemicals. White rice, quinoa, buckwheat, millet are non-gluten
grains that are tolerated by most people. Some people who do not
tolerate other gluten grains can tolerate oats in small amounts.

Some special foods that protect the liver:
Beef consumption is related to lower rates of cirrhosis, and this is
probably true for all red meats. The same is true for eggs. However
pork and processed meats (which are mainly pork) may increase
cirrhosis. Red meats are best.
Spices, including turmeric, fenugreek, saffron, garlic, vanilla are
protective against fibrosis.
Coffee consumption protects against fibrosis and cirrhosis from
alcohol and possibly Hepatitis C. Green tea (and possibly black tea)
protects against fibrosis, but this effect may be reduced by milk in
DHA from oily fish is protective against fibrosis in moderate
supplement doses but may increase it in excessive amounts.
Lecithin, betaine and choline protect against fatty liver; these are
found in eggs, chocolate, liver and kidney, and fish roe (lecithin and
choline), and in beetroot and spinach (betaine).
Beetroot contains betaine and some unusual and potent antioxidants,
betalains, which are destroyed by cooking (boil beetroot for less than
15 minutes, roast for under 1 hour).
Vitamins A and K2 protect against liver cancer and are found in animal
fat, organ meats, fermented dairy foods, and (K2 only) spirulina and
fermented soy.
Brazil nuts are the richest source of selenium, which also protects
against liver cancer and fibrosis. Each nut contains 19mcg selenium; 4
a day is enough. Meat and seafood are also good sources of selenium.
Carotenoids, folic acid, and flavonoids protect against fibrosis and
are found in green leafy vegetables; sulfur compounds found in
cruciferous veges (cabbage, broccoli, mustard, radish etc.) stimulate
immunity and protect against cancers.
OPCS, astringent polyphenols found in grape seed, pine bark, cocoa,
berries, and apples, protect the circulation of the liver, and protect
against the blood cancers (lymphoma) associated with both Hepatitis C
and coeliac disease.
Chinese mushrooms such as shiitake, black and white fungus, etc.
(dried or fresh) have benefits for the liver and immune system.

Eat FOOD: don’t eat food products. If possible cook it yourself or eat it raw.
These canned foods are good: sardines, tuna, mackerel: tomatoes,
beans, beetroot: olives; and bottled (not canned) pasta sauces. Frozen
vegetables and berries are excellent foods. Prunes and raisins are
good dried fruits.
MTR boil-in-a-bag curries are good occasional convenience foods.
Try to avoid processed meats, pure beef or venison sausages are the
best varieties.
It is not necessary to try to eat all the special foods. These are
good if you have them and like them, but you will not die from their
Eat some red meat, eggs, and occasional fish; some dairy (especially
butter, cream, yoghurt, or aged cheese) if this suits you; some
starchy vegetables (potato, kumara, carrot, swede, yam, beetroot,
peas, etc.); some green vegetables - raw or cooked (spinach, cabbage,
cauliflower, celery, lettuce, etc,); and some fruit or berries. Use
spices, onion, garlic, extra virgin olive oil, or herbs for
flavouring. Eat fresh nuts and seeds in moderation if you like. Enjoy
dark chocolate, coffee, tea, herb tea, fruit tea, as far as possible
unsweetened (cream can be a good substitute for sugar in coffee and
cocoa). Drink clean water regularly. Do not overdose on “fibre”.
Cook food at lower temperatures (below 200C in the oven; 170C is good
for roasting most things), remember water in a dish (as with soups and
casseroles) helps to control temperature, and fry and roast with
traditional fats, especially beef and lamb dripping, or butter and
ghee. If a meal needs oil use extra-virgin olive oil. Pan-roast chips
rather than deep-frying.

Some references:
Dietary Fat and Alcoholic Liver Disease; a concise review. Esteban Mezey
Alcohol and dietary intake in the development of chronic pancreatitis
and liver disease in alcoholism.  E Mezey, et al.
Fructose, PUFA and Gluten papers linked to Hyperlipid blog (use blog
search function)
Gluten Grains, Carbohydrates and Fats sections of Archevore blog (ditto)
Beef fat Prevents Alcoholic Liver Disease in the Rat; Nanji et al.
Relationship between Dietary Beef, Fat, and Pork and Alcoholic
Cirrhosis; Bridges
Dangerous Grains; book by Hogan and Braley.
Life Extension Foundation website: Health Concern: Hepatitis C (for
advice on supplements and drugs)
Applying principles of HCV virology to the Development of new
Antiviral Therapies; Stephen J. Polyak

(c) George D Henderson 2012

Feel free to use this.

A video of my 2009 working holiday in New Zealand's scenic Southern Alps. Music: Walrus Arabia, by The Puddle. I'm the one with the moustache and the guitar, Gavin wears the hat and the bass, and my brother Ian was behind the camera, the drumkit, and the steering wheel.


Wout Mertens said...

Great summary!

Some nitpicks:
- I recently heard an interview with a fructose researcher saying that only 25% of fructose undergoes hepatic de novo lipolysis, the rest is taken up by any cell with GLUT5 receptors including muscle and testes. Of course even 25% may be enough to trigger issues.
- folate, not folic acid
- the WAPF did some research into pork and they found that if the pork was cured (bacon!) or marinated (ribs!), there were no issues. It's only fresh pork that is an issue (sausages :-( ).

In any case I'm bookmarking this one :-)

Wout Mertens said...

...lipogenesis of course. I should have said "is converted to fat in the liver" but I love typing hepatic :-)

Puddleg said...

Yes, fructose use may vary, however if I'm addressing people's energy drink consumption (e.g.) that's a pretty hefty load, and other issues like ATP depletion and uric acid elevation are coming into play.
And I'm only considering DNL fat that might be retained by the liver and contribute to steatohepatitis, not an obesigenic mechanism.
Yup, the salted pork seems to be safer.
I guess I eat pork because it's cheap and I like it, but if I started to develop cirrhosis I'd cut it out altogether, even if I still didn't understand the exact connection. It's not like I'd run out of meat to eat and fat to cook with. I compromise at present by cooking bacon and pork mince in lamb and beef dripping to decrease omega-6 PUFA load.

Unknown said...

I have low LDL/HDL would you recommend Flax seed oil?

Puddleg said...

For correcting omega 6:3 ratios, krill oil is better than fish oil, which is better than flaxseed.
For elevating HDL/LDL, highly saturated animal fats (such as beef and/or lamb dripping) or coconut oil are probably the safest and most reliable way. And eating high-cholesterol foods, such as eggs and offal, while it probably will not raise LDL, will supply some of the cholesterol that the body (including the brain and immune system) needs, and that the liver doesn't make enough of in viral hepatitis.
Getting more antioxidants and some vitamins can help raise HDL, while smoking and some toxins can lower it.

Puddleg said...

If you are currently cooking with oils, and you switch to using dripping (tallow) and butter (or ghee) - and some coconut oil or cream - this should elevate HDL and LDL.
Significant amounts of fats from seed oils - corn, soy, sunflower, safflower, rice bran, canola etc - may keep cholesterol artificially low (as well as stressing an inflamed liver or gut).

Puddleg said...
This comment has been removed by the author.
Puddleg said...

Also see the studies linked in this post,
which show that higher selenium intakes can elevate cholesterol by 10-15%.
It's a good idea to supplement selenium (or seek a selenium rich diet) if you have HCV or HBV.
150mcg daily is probably adequate, but up to 400mcg has been tolerated by many people for long periods.
Check the selenium content of the soil in your area on the selenium maps online; a few places, such as Wyoming, have naturally high levels, but most of the US, Eurpoe and Africa don't.

Unknown said...

Hi George,
What is your opinion of fasted
exercise on liver health?

Puddleg said...

Purely my own experience, that it's easier to exercise in the fasted state; exercise fed, and the liver must supply energy for digestion as well as exertion. So I always feel stronger and get more done if I exercise before lunch, on a coffee and cream, maybe a piece of fruit, but not much else.
It makes sense in evolutionary terms that hunger was the spur to exertion, feeding led to relaxation.

honora said...

Hi George - enjoyed the scenes of the Craigieburns, Arthurs Pass and you lads standing around in the snow. Glad there was a shot of a kea in there as well. Classic! And of course, the jangly Dunedin sound.

Puddleg said...

Thanks - it's actually my favourite Puddle video.

Unknown said...

Hey George,
In case you haven't seen it, the Primal Docs site have a new post about liver health:

Wout Mertens said...

So does this need updating or does it stand as is?

One thing that jumped out for me was the brazil nuts, they vary wildly in their selenium content plus selenium overdose isn't great, which is why Paul Jaminet took them out of the perfecthealthdiet recommendations, preferring supplementation or simply getting it from food like eggs.

Puddleg said...

I think it stands but I might be easier on the non-gluten grains and non-soy legumes today.

Brazil nuts don't really vary much as sold in supermarkets, and there are no cases of selenosis from nuts on record.

The high-Se nuts are some special amazonian breed that you'd pay a premium for.

Unknown said...

Hello. I wrote a post on how to keep your liver healthy if anybody is interested in taking a look. I think you have covered most of it in this, but just in case I have covered some missing here are some more tips for you on how to keep your liver healthy

Unknown said...

Hi George, me again. I've been improving rapidly in part thanks to your recommendations so I am very grateful.

I'm curious what you think of silymarin/milk thistle? This time I'm asking for my girlfriend. She has a long history of very heavy drinking ( in addition to overall poor eating habits ).

I came across this . I'm not sure what they mean by high fat diet, but I assume it was pretty high in n-6 PUFA given the negative effects. Silymarin was very protective at a dose of 30mg/kg in the mice.

Do you think it's worth supplementing for her situation?

We eat more or less according to what you outline here.

Puddleg said...

Wow, they really give zero information about their high-fat diet!
But I expect it is lard and soybean oil, high in PUFA and relatively low in SFA, and the mouse used is bred to get fat on fat; see my latest post for details on this mouse.

Silymarin is good stuff, I took it for years - and the effects on insulin sensitivity in the mice look good. Silymarin also has a mild antiviral effect.

shend said...

I also have Hep C and my numbers aren't good, but I don't go to the doctor enough to really know what is going on. I am wondering what you think of the Zero Carb diet I have been eating just red meat and drinking water now for 2 weeks. Already I am feeling better.

Puddleg said...

Hi Shend,

I think the zero carb diet will improve Hep C, in fact, if you can tolerate it, then it is probably the best diet of all as it removes everything that you could possibly have an issue with, while giving you enough nutrition to be going on with.

Some people add offal and fatty meat to cover all their nutritional bases, others seem to do okay for years just on muscle meat, which is fairly limited in some micronutrients.

Here we have a paleolithic ketogenic diet, which is in some cases all meat and offal, but in this case included some veges and even small amounts of honey, in the treatment of a liver condition.

"This diet is based on animal fat, meat, eggs and offal and to a lesser extent (less than 30%) vegetables and fruits. Fat to protein ratio was at least 2:1 (in gram). Fat and red meats derived from pork and cattle were encouraged over lean meats from poultry. She consumed offal from pork and cattle (predominantly liver, brain and marrow) at least two times a week. She was avoiding foods with additives including nitrites and/or nitrates. Foods that are allowed or even encouraged in the popular paleolithic diet such as artificial sweeteners, coconut oil, oilseeds, oilseed flours and cocoa were excluded. She used small amounts of honey."

There are other papers from these authors where the patients ate no vegetable foods.

shend said...

Thank you, George. I plan on eating fatty meats, offal, some fish and as a side, eggs. I had to do something as for the past 3 months all I can do is sleep and sit.

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